Medical Review Specialist

3 weeks ago


Warwick, Rhode Island, United States HMS Full time
Unlock Your Career Potential in Medical Review

We are seeking a skilled Medical Review Specialist to join our team at Gainwell Technologies. As a key member of our healthcare solutions group, you will utilize your clinical expertise to perform case reviews of Medicaid claims data, identifying potential fraud, abuse, and quality of care concerns.

The ideal candidate will possess a deep understanding of Medicaid policies and procedures, as well as excellent analytical and communication skills. This is a full-time, permanent position with a competitive salary range of $64,500 - $92,200 per year, depending on location and experience.

Key Responsibilities:

  • Apply clinical knowledge to Medicaid claim data to identify possible issues of fraud or abuse of Medicaid benefits, quality of care concerns or non-compliance with existing policy.
  • Research individual cases, summarize findings, and present recommendations to the customer using independent clinical judgment and established protocols.
  • Collaborate with cross-functional teams to develop and implement effective case review strategies.

Requirements:

  • Registered Nurse with at least 5 years of clinical experience.
  • Strong analytical and problem-solving skills.
  • Excellent verbal and written communication skills.
  • Familiarity with claim review and coding experience (CPT, ICD9, HCPCS) necessary.

About Gainwell Technologies:

Gainwell Technologies is an industry leader in healthcare solutions, dedicated to creating innovative solutions that improve healthcare outcomes for all. We offer a dynamic work environment, competitive salaries, and opportunities for career growth and development.



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